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Reemergence of Strongyloidiasis, Northern Italy View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by PubMed Central LETTERS coln Marsh (38/81, 46%). The number density, these attractants should be re- 5. Gavin PJ, Kazacos KR, Shulman of latrines per backyard ranged from 1 moved. Homeowners with small chil- ST. Baylisascariasis. Clin Microbiol Rev. 2005;18:703–18. DOI: 10.1128/ to 6 (χ = 2.15). B. procyonis eggs were dren should remove latrines as quickly CMR.18.4.703-718.2005 found at 14/61 latrines sampled (23%; as they are discovered (2). The risk 6. Page LK, Swihart RK, Kazacos KR. 95% CI 12%–34%), and no significant of children acquiring potentially fa- Raccoon latrine structure and its poten- difference in prevalence was found tal baylisascariasis can be reduced if tial role in transmission of Baylisascaris procyonis to vertebrates. Am Midl Nat. between the Ned Brown (6/23, 26%; parents understand how to reduce the 1998;140:180–5. DOI: 10.1674/0003- 95% CI 8%–44%) and Lincoln Marsh likelihood that children will come into 0031(1998)140[0180:RLSAIP]2.0.CO;2 areas (8/38, 21%; 95% CI 8%–34%). contact with raccoon latrines. 7. Sloss MW, Kemp RL, Zajac AM. Vet- Evaluation of the main effect erinary clinical parasitology. Ames (IA): Iowa State University Press; 1994. model identified a decreasing prob- Acknowledgments 8. Page LK, Swihart RK, Kazacos KR. Im- ability of latrine occurrence with in- The authors thank the Cook County plications of raccoon latrines in the epi- creasing distance from the nearest Forest Preserve District, the Elk Grove Vil- zootiology of baylisascariasis. J Wildl Dis. 1999 35 474 80 forested area and the presence of an lage, the Illinois Health Department, and the ; : – . outdoor pet, although these relation- numerous cooperating homeowners in both Address for correspondence: L. Kristen Page, ships were only marginally significant Elk Grove Village and Wheaton, Illinois. (p = 0.07 and 0.08, respectively). No Biology Department, Wheaton College, 501 other variables were closely associated This study was supported by the College Ave, Wheaton, IL 60187, USA; email: with the presence of raccoon latrines Wheaton College Alumni Association, the [email protected] (p>0.20). When evaluated alone, dis- Aldeen Fund, and the Science Division of tance from the forest preserve was sig- Wheaton College. nificantly related to latrine occurrence (p = 0.03); probability decreased with L. Kristen Page, Chris Anchor, increasing distance. Evaluation of the Ellen Luy, Sarah Kron, simplified model identified a weakly Grace Larson, Lauren Madsen, positive association with the pres- Kenneth Kellner, Reemergence of ence of a food source (p = 0.09) and and Timothy J. Smyser Strongyloidiasis, no association with the presence of Author affiliations: Wheaton College, latrine substrate (p = 0.35). Although Wheaton, Illinois, USA (L.K. Page, E. Luy, Northern Italy the findings were not statistically sig- S. Kron, G. Larson, L. Madsen, K. Kellner); To the Editor: Strongyloidi- nificant, raccoon latrines did appear to Wildlife Division of the Forest Preserve asis is a helminth infection caused by be associated with the availability of District of Cook County, Elgin, Illinois, USA Strongyloides stercoralis, a nematode a food source such as bird feed (odds (C. Anchor); and Purdue University, West ubiquitous in tropical and subtropical ratio [OR] 1.9, 95% CI 0.9–4.1); the Lafayette, Indiana, USA (T.J. Smyser) countries and occasionally reported in presence of an outdoor pet (OR 0.27, DOI: 10.3201/eid1509.090128 temperate countries, including Italy 95% CI 0.06–1.2) and increasing dis- (1). Sources of infection are filariform tance from the nearest forested area References strongyloid larvae present in soil con- reduced the likelihood of latrines. No taminated by infected feces; the larvae other variables were associated with 1. Kazacos KR. Protecting children from penetrate through the skin of a human the presence of raccoon latrines; how- helminthic zoonoses. Contemp Pediatr. 2000 17 1 24 host. After the first life cycle, a process ever, low statistical power may have ; : – . 2. Kazacos KR. Baylisascaris procyonis and of autoinfection begins, which persists precluded adequate assessment. related species. In: Samuel WM, Pybus indefinitely in the host if the infection Our results suggest that when hu- MJ, Kocan AA, editors. Parasitic diseases is not effectively treated. The infec- mans live close to protected forests of wild mammals. Ames (IA): Iowa State 2001 tion can remain totally asymptomatic or natural areas, they are more likely University Press; . 3. Sorvillo F, Ash LR, Berlin OGW, Yatabe for many years or forever or cause cu- to attract raccoons into their yards. In J, Degiorgio C, Morse SA. Baylisascaris taneous (itching and rash), abdominal addition, anthropogenic food sources procyonis: an emerging helminthic zoono- (epigastric pain, pseudoappendicitis, such as pet food, garbage, and bird sis. Emerg Infect Dis. 2002;8:355–9. 4 Pai PJ Blackburn BG Kazacos KR War- diarrhea), respiratory (cough, recur- feed may increase the likelihood that . , , , rier RP, Begue RE. Full recovery from rent asthma), and systemic (weight a raccoon will create a latrine, and the Baylisascaris procyonis eosinophilic loss, cachexia) symptoms that can be presence of outdoor pets appears to be meningitis. Emerg Infect Dis. 2007;13: enervating. More importantly, when a deterrent. In areas of high raccoon 928–30. host immunity is impaired because of Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 9, September 2009 1531 LETTERS a concurrent disease or immunosup- leukocyte count/formula) for what- year (of whom some are anecdotally pressive therapy (including corticos- ever reason and having a eosinophil reported as dying from the infection, teroids, sometimes used to treat symp- count >500 cells/μL was asked to join usually unpublished), we suspect that toms of the unrecognized infection the study. This study was the pilot most strongyloidiasis cases remain or the concurrent eosinophilia), dis- phase of a larger, multicentered study, undetected. seminated strongyloidiasis may occur which obtained formal approval from If relevant transmission still ex- (2–4), causing a massive and almost the Ethical Committee of Sacro Cuore ists in the area, it is unknown but is invariably fatal invasion of virtually all Hospital of Negrar, Verona. Informed unlikely because of the improvement organs and tissues by filariform larvae consent was required of each patient. of hygienic conditions in the past and even adult worms (Figure), often Of the 132 patients eligible for inclu- 5 decades. Reports of the infection combined with bacterial superinfec- sion (mean age 76.4 years, range 68– in children or young adults with no tion. This complication is believed to 90 years, male:female ratio 1.6), none travel history outside Italy are lack- be rare but is probably underestimated refused to give informed consent. Se- ing. Strongyloidiasis in the elderly is because of the extreme variability of rum specimens were subjected to the therefore most likely to result from an the clinical presentation. IFAT for S. stercoralis at the Sacro infection that occurred much earlier Although strongyloidiasis can be Cuore Hospital Centre for Tropical in life, either in infancy or at a young suspected in the presence of symptoms Diseases. age, while walking or working bare- or eosinophilia (which is frequent but Unexpectedly, we found that 37 foot in agricultural fields. The long not mandatory), the low sensitivity of (28%) of 132 patients were positive, persistence is the consequence of the direct diagnostic methods often lets with titers ranging between 20 and autoinfection cycle typical of this par- the disease go unrecognized (5–7). >320 (and >80 in most cases). How- asite as described above. The result is By far the most sensitive diagnostic ever, caution should be exercised an important and unrecognized public tools are serologic tests: sensitivity in interpreting the results because health problem affecting the geriatric and specificity of indirect fluorescent the patients may not be representa- population of northern Italy. These antibody test (IFAT) (in-house pro- tive of the general population. More- preliminary results confirm the need duced IFAT) are 97.4% and 97.9%, over, our results are based on an in- for the already planned, multicentered respectively, at a dilution >1/20, and direct (although highly sensitive and study involving a larger sample and a 70.5% and 99.8% at a dilution >1/80 specific) test. Because the reported wider geographic area. (6). A suspected case is defined by a cases involve only a few patients every positive antibody titer >20 (IFAT); a case is confirmed by a positive direct test result (culture in agar being the most sensitive direct technique) or by a positive antibody titer >80 (6). Despite some anecdotal reports on the presence of strongyloidiasis in Italy (1,6), reliable information about the real prevalence of the infection is lacking. After seeing several patients affected by the disease, 1 of whom died because of dissemination (Z. Bisoffi, unpub. data), we decided to carry out a preliminary rapid assess- ment of the extent of the problem in elderly patients with eosinophilia. During a 4-month period, from February through May 2008, every patient born in 1940 or earlier who came to the clinical laboratories of 2 contiguous health districts in northern Italy (Mantova, Lombardy Region, Figure. Adult female of Strongyloides stercoralis collected in bronchial fluid of a patient with and Legnago, Veneto Region) for a disseminated disease. Scale bar = 400 µm. A color version of this figure is available online diagnostic blood test (hematocrit and (www.cdc.gov/EID/content/15/9/1531-F.htm). 1532 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 9, September 2009 LETTERS Fabrizio F. Abrescia, Address for correspondence: Fabrizio F.
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